Tuesday, 4 December 2012

On Being Observed While Doing Your Job

The Masked AMHP (in a suit) attempting to interview in a suitable manner -- with hilarious results. Publicity shot from the stage production of "Ooer, Missus, It Shouldn't Happen to an AMHP!" ﻿

Every five years,
AMHP’s have to provide evidence to their local authority of their competence to
continuing practicing. One of my local authority’s recent mandatory
requirements for being reapproved in the role of Approved Mental Health
Professional is to be critically observed and assessed while actually
undertaking a live Mental Health Act assessment. Scary or what?

Although there are
many professions who are often in the public eye while doing their jobs (teachers,
police officers and nurses to name just
three), AMHP’s are possibly more closely scrutinised while performing their
duties than most.

A typical MHA
assessment in someone’s home, as well as the patient, of course, can easily
include two doctors, two or more police officers, a couple of ambulance crew,
the nearest relative, and the patient’s care coordinator. There can also be an
AMHP trainee shadowing the AMHP, and possibly even students from other
professions. That’s a possible total of 11 or even more. And some of them may
be fairly hostile to the AMHP’s role, especially if they’ve formed their own
lay assessment of the situation.

While Mental Health Cop on his blog is valiantly attempting to educate his colleagues on the law
relating to people with mental disorders, police officers nevertheless often
find it difficult to understand the factors that AMHP’s legally have to take
into account when assessing a patient for possible compulsory hospital
admission. And ambulance drivers and paramedics often have alarmingly little
knowledge which they are then very keen to exercise.

The nearest relative
or other carers will frequently be experiencing a range of distressing
emotions, and whatever decision you make may be a source of additional distress
to them. They may be reluctant to recognise that their relative needs to be
admitted to hospital. They may be upset by a decision to admit, as it means
acknowledging that they can’t cope with the behaviour of their loved one any
more any longer. Equally, they may be upset by a decision not to admit.

All of this means that
AMHP’s often have to explicitly articulate the process of assessment to others,
almost in the way that a surgeon may narrate a procedure to medical students
and other junior staff in the operating theatre.

This is, of course, no
bad thing. A vital part of the AMHP role is to know at all times what one’s
legal powers and responsibilities are, and to be able to explain this to all others
involved in the assessment in such a way that it can be clearly understood.

The patient needs to
know why you are there and what you are doing; the nearest relative needs to
understand their specific role as the NR within the meaning of the MHA; and you
may need explain to ambulance crews and police officers what their legal powers
and obligations are in assisting the AMHP to manage the overall process.

And when the
assessment has been completed, the AMHP has to write a formal report on the
assessment in which they will need to justify their actions and decisions in
case of future challenge.

After a while, stage
fright can be overcome, and the AMHP can perform their functions with quiet
competence. Being a still point of confidence and calm in the midst of chaos
and fear can be of enormous importance.

Nevertheless, there
are few professions who are subject to a formal assessment of their competence
in such a live situation. Teachers are one such profession, as they have to
teach a class in front of OFSTED inspectors when required, with hardly any
notice.

Being shadowed by a
student or trainee AMHP is something I actually rather enjoy. It keeps me on my
toes, it makes me think very carefully and explicitly about why I do what I do
and why I make the decisions I do. Trainee AMHP’s in particular are good at
asking awkward questions during the subsequent debriefing (Why did you do that?
Why did you say that? Wouldn’t it have been better if you’d done so and so?)

So the day came when
it was planned that one of my AMHP colleagues would shadow me while doing a MHA
assessment. We sat together in the AMHP office, where the day’s duty AMHP’s sit
and wait for referrals to come through. And a referral did indeed come.

Aaron was a 19 year
old young man who lived with his parents. He was a patient of the Early
Intervention in Psychosis Team, as he had presented a few months ago with the
first symptoms of psychosis. But he also had marked autistic spectrum traits.
He had been fairly well controlled with an oral antipsychotic, but because of
side effects, the dose had been reduced, and his
behaviour had become more disruptive and difficult for his parents to manage.

His mother had taken him to see his GP, but
he had become anxious and agitated and had run out into the street, ignoring
traffic and potentially putting himself at risk. The police had been called,
who quickly apprehended him, and because of his continuing behaviour in the
police car, during which he almost succeeded in climbing out of the window and
onto the roof of the moving vehicle, he was taken to the S.136 suite.

And that was where he was on referral.

From the moment of taking the call, I was
being observed and assessed. My actions and decisions were being constantly
monitored – arranging for a Sec.12 doctor to attend, speaking to the patient’s
mother and establishing which of the parents was the NR for the purposes of the
MHA, consulting with the Early Intervention Team to get background information,
and scanning the patient’s electronic notes.

My AMHP observer, the
Sec.12 psychiatrist and I went together to the S.136 suite, where two police
officers and his mother were with the patient.

I explained to
Aaron what my role was and what tasks I had to undertake. He stared at me
fixedly, then as soon as I had finished said, “Can I go home now?”

This was a
frequent response to questions I asked him throughout the assessment. He
appeared to have only limited understanding of the reasons for his detention
and the purpose of the assessment, despite my attempts to explain this to him.
Throughout the assessment he maintained fixed eye contact and displayed no
facial expression or emotion, although there was implicit evidence of agitation
and anxiety. However, he was unable to verbally acknowledge or express this.

He was very
guarded during the assessment and was reluctant to discuss any possible
psychotic phenomena. He often only answered questions with yes or no answers,
and had difficulties with open questions. He eventually said that he had left
the doctor’s surgery because he had been disturbed by the doctor’s use of the computer,
but refused to enlarge on this. He said that he was willing to take medication
and willing to engage with the EIT or the CRHTT if considered necessary. His
preference was to return home.

So what would my
decision be? I needed to use the information I had obtained, combined with the
consultation with the patient, and with his mother.

The Early
Intervention Team told me that Aaron had been considered a few weeks ago for
compulsory detention, but they had concluded that he could be managed by them
in the community. They had also concluded that in view of his autistic spectrum
traits, admission to an acute psychiatric ward would be likely to make him
worse, and increase his anxiety and agitation. They told me that they would be
happy to continue with this plan.

His mother, on the
other hand, was concerned about her ability to stand up to Aaron’s demands on
her, and worried about how to respond if for example he went off on his bike.
However, she did concede that he was capable of cycling from their village into
Charwood, where he would go into shops or go to the library. Although she was
not prepared to say it openly, I could tell that she would rather he was
admitted to hospital.

The psychiatrist
was doubtful that compulsory admission was indicated. The discussion with him
was helpful. In conjunction with the psychiatrist, the Early Intervention Team,
and Aaron and his mother, a short term plan was constructed.

Aaron would not be
admitted to hospital. The psychiatrist recommended a change to his medication,
and he was also given some diazepam that his GP had prescribed. The Early
Intervention Team would increase their input in the short term. The
psychiatrist spoke to the GP on the phone in the S.136 suite and faxed his
assessment and recommendations to the surgery.

This plan would be
open to constant review, and it was made clear to Aaron that if his mother felt
unable to manage his behaviour, then a further assessment would become
necessary.

Aaron and his
mother went home. The police officers vacated the S.136 suite. My observer and
I returned to the AMHP office for an in depth debrief. And of course, I had my
assessment report to write.

At the end of it
all, it felt quite satisfying. I had quite enjoyed the experience of being
formally assessed. It was all part of the job.

2 comments:

wow this is very almost identical to an assessment i did the other day, save the s136 suite.....same anxities about admitting someone with these needs to an acute unit and the effect this would have on his ASD............

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.